Instructions: This checklist is
meant to serve as a general guideline for our client facilities as to the
level of your skills within your nursing specialty. Please use the scale
(PROFICIENCY)
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
(FREQUENCY)
1 = Never performed observed only
2 = Less than 6 times per year
3 = 1-2 times per month
4 = Daily or Weekly
PROFICIENCY / FREQUENCY
PROFICIENCY
FREQUENCY
Anal Fistulectomy/Anoplasty
Appendectomy/Cholecystectomy
Biopsy (Mass, Muscle, Lymph Node)
Esophagogastroduodenoscopy w/ Biopsy
Insertion of Port-a-Cath, Hickman, Broviac
Laparascopic General Surgery Procedures
Percutaneous Endoscopic Gastrostomy
Thoracoscopy/Nuss Procedure
Scrub Peds General Surgery
Aorto-Bifemoral/Femoral-Pop Bypass Graft
Endoscopic Vascular Procedures
Femoral Popliteal Bypass Graft
Laparascopic Cardiac Surgery
Robotic Assisted Cardiac Surgery
Ventricular Assist Device
Endoscopic Thoracic Procedures
Mediastinotomy/Sternotomy
Thoracoscopy/Nuss Procedure
Closed Reduction of Fracture
Anterior Cruciate Ligament Reconstruction
Open Reduction Internal Fixation
Steriotactic Guided Brain Biopsy
Laparoscopic Anterior Laminectomy
Insertion of Vagal Nerve Stimulator
Anterior Cervical Discectomy with Fusion
Posterior Cervical Laminectomy
Scrub Neurological Surgery
Cystoscopy/Cystogram/Pyelogram
Anterior Posterior Repair
Laparoscopic Assisted Hysterectomy
Laparotomy with Microtuboplasty
Robotic Assisted GYN Procedures
Suspension Microlaryngoscopy
Tonsillectomy & Adenoidectomy
Tympanoplasty/Typanomastoidectomy
Craniofacial Reconstruction
Leforte 1 Maxillary/Sagittal Osteotomy
Repair of Cleft Lip, Nose, Palate
Breast Reconstruction with Implant
Breast Reduction Mammoplasty
Mastectomy with Tram Flap Reconstruction
Split Thickness Skin Graft
Insertion of Vagal Nerve Stimulator
ECMO Insertion/Decannulation (Cardiac)
Repair of Coarctation of Aorta
Tetralogy of Fallot Repair
Ventricular Assist Device
Scrub Peds Cardiac/Vascular
CRANIOFACIAL/ORAL/PLASTICS
Craniofacial Reconstruction
Leforte 1 Maxillary/Sagittal Osteotomy
Repair of Cleft Lip, Nose, Palate
Scrub Peds C-Fl/Oral/Plastics
Acetabuloplasty/Triple Innominate
Arthroscopy of Knee, Wrist, Shoulder
Closed Reduction, Percutaneous Pin
External Fixator (Ilizarov/Orthofix)
ORIF Shoulder, Humerus, Tibia, Femur
Osteotomy/VDRD/Calcaneal/Metatarsal
Spinal Fusion/Spinal with Instrumentation
Tendoachilles Lengthening
OR Fracture Tables (List Types)
Orthopedic Total Joint Systems
Robotics Systems (List types)
Spinal Fusion Instrumentation
PROFESSIONAL KNOWLEDGE AND SKILLS
Malignant Hyperthermia Protocol
Administer and Monitor Moderate Sedation
Universal Protocol for Wrong Site Surgery
National Patient Safety Goals/Core Measures
Fall Risk Assessment/Prevention
Pressure Ulcer Risk Assessment/Prevention
Restraints/Use of Least Restrictive Device
Age Specific/Population-Based Care
Other Computerized System
Computerized Physician Order Entry